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Zdęba-Mozoła A, Kozłowski R, Rybarczyk-Szwajkowska A, Czapla T, Marczak M. Implementation of Lean Management Tools Using an Example of Analysis of Prolonged Stays of Patients in a Multi-Specialist Hospital in Poland. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:1067. [PMID: 36673823 PMCID: PMC9858728 DOI: 10.3390/ijerph20021067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 01/02/2023] [Accepted: 01/04/2023] [Indexed: 06/17/2023]
Abstract
Healthcare institutions in Poland constantly encounter challenges related both to the quality of provided services and to the pressures associated with treatment effectiveness and economic efficiency. The implemented solutions have a goal of improving the service quality of lowering the continuously increasing operational costs. The aim of this paper is to present the application of Lean Management (LM) tools in a Polish hospital, which allowed for the identification of prolonged stays as one of the main issues affecting the service costs and the deteriorating financial results of the hospital. The study was conducted in the neurology department and involved an analysis of data for the whole of 2019 and the first half of 2022. In addition, surveys were conducted among the medical staff to help identify the main causes of prolonged stays. Methods of data analysis and feasible solutions were developed in order to improve the economic efficiency of the unit. The analysis shows that the application of LM tools may contribute to improvement in the functioning of hospitals and that further studies should focus on the development of the method to evaluate efficiency of the implemented solutions intended at shortening the hospital stays of the patients.
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Affiliation(s)
- Agnieszka Zdęba-Mozoła
- Department of Management and Logistics in Healthcare, Medical University of Lodz, 90-131 Lodz, Poland
| | - Remigiusz Kozłowski
- Centre for Security Technologies in Logistics, Faculty of Management, University of Lodz, 90-237 Lodz, Poland
| | | | - Tomasz Czapla
- Department of Management, Faculty of Management, University of Lodz, 90-237 Lodz, Poland
| | - Michał Marczak
- Department of Management and Logistics in Healthcare, Medical University of Lodz, 90-131 Lodz, Poland
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Hung DY, Lee J, Rundall TG. Transformational Performance Improvement: Why Is Progress so Slow? Adv Health Care Manag 2022; 21:23-46. [PMID: 36437615 DOI: 10.1108/s1474-823120220000021002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
In this chapter, we identify three distinct transformational performance improvement (TPI) approaches commonly used to redesign work processes in health care organizations. We describe the unique components or tools that each approach uses to improve the delivery of health services. We also summarize what is empirically known about the effectiveness of each TPI approach according to systematic reviews and recent studies published in the peer-reviewed literature. Based on examination of this research, we discuss what knowledge is still needed to strengthen the evidence for whole system transformation. This involves the use of conceptual frameworks to assess and guide implementation efforts, and facilitators and barriers to change as revealed in a recent evaluation of one major initiative, the Lean Enterprise Transformation (LET) at the Veterans Health Administration. The analysis suggests ways in which TPI facilitators can be developed and barriers reduced to improve the effectiveness and sustainability of quality initiatives. Finally, we discuss appropriate study designs to evaluate TPI interventions that may strengthen the evidence for their effectiveness in real world practice settings.
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Affiliation(s)
| | - Justin Lee
- University of California at Berkeley, USA
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Lean six sigma in the healthcare sector: A systematic literature review. MATERIALS TODAY. PROCEEDINGS 2022; 50:773-781. [PMID: 35155129 PMCID: PMC8820448 DOI: 10.1016/j.matpr.2021.05.534] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 05/05/2021] [Accepted: 05/08/2021] [Indexed: 11/21/2022]
Abstract
Healthcare is a very important sector as our lives depend on it. During the novel corona virus pandemic, it was evident that our healthcare organizations still lack in terms of efficiency and productivity. Especially in the developing nations, the problems were much bigger. Lean Six Sigma (LSS) is a methodology which when implemented in an organization, helps to increase the process capability and the efficiency, by reducing the defects and wastes. The present study systematically reviews the research studies conducted on LSS in the healthcare sector. It was found that comparatively less studies are focused on improving the medical processes, most of the studies targeted the management processes. Moreover, lesser number of studies were being conducted for developing nations, but now it seems that the focus of research scholars has shifted towards the developing nations also. But it was observed that the studies in these nations were majorly empirical in nature, very few studies were conceptual or exploratory. There is a need for guiding healthcare professionals on creating a continuous improvement environment, which sustains the improvements achieved after LSS implementation.
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Schretlen S, Hoefsmit P, Kats S, van Merode G, Maessen J, Zandbergen R. Reducing surgical cancellations: a successful application of Lean Six Sigma in healthcare. BMJ Open Qual 2021; 10:bmjoq-2021-001342. [PMID: 34462263 PMCID: PMC8407222 DOI: 10.1136/bmjoq-2021-001342] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 08/09/2021] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE The COVID-19 pandemic emphasises the need to use healthcare resources efficient and effective to guarantee access to high-quality healthcare in an affordable manner. Surgical cancellations have a negative impact on these. We used the Lean Six Sigma (LSS) methodology to reduce cardiac surgical cancellations in a University Medical Center in the Netherlands, where approximately 20% of cardiac surgeries were being cancelled. METHOD A multifunctional project team used the data-driven LSS process improvement methodology and followed the 'DMAIC' improvement cycle (Define, Measure, Analyse, Improve, Control). Through all DMAIC phases, real-world data from the hospital information system supported the team during biweekly problem-solving sessions. This quality improvement study used an 'interrupted time series' study design. Data were collected between January 2014 and December 2016, covering 20 months prior and 16 months after implementation. Outcomes were number of last-minute coronary artery bypass graft cancellations, number of repeated diagnostics, referral to treatment time and patient satisfaction. Statistical process control charts visualised the change and impact over time. Students two-sample t-test was used to test statistical significance. A p<0.05 was considered as statistically significant. RESULTS Last-minute cancellations were reduced by 50% (p=0.010), repeated preoperative diagnostics (X-ray) declined by 67% (p=0.021), referral to treatment time reduced by 35% (p=0.000) and patient Net Promoter Score increased by 14% (p=0.005). CONCLUSION This study shows that LSS is an effective quality improvement approach to help healthcare organisations to deliver more safe, timely, effective, efficient, equitable and patient-centred care. Crucial success factors were the use of a structured data-driven problem-solving approach, focus on patient value and process flow, leadership support and engagement of involved healthcare professionals through the entire care pathway. Ongoing monitoring of key performance indicators is helpful in engaging the organisation to maintain continuous process improvement and sustaining long-term impact.
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Affiliation(s)
- Stijn Schretlen
- Integrated Health Solutions, Medtronic plc, Maastricht, Nederland, The Netherlands .,Heart+Vascular Centre, Maastricht University Medical Centre+, Maastricht, Limburg, The Netherlands
| | - Paulien Hoefsmit
- Cardiothoracic Surgery, Amsterdam UMC Locatie AMC, Amsterdam, North Holland, The Netherlands
| | - Suzanne Kats
- Heart+Vascular Centre, Maastricht University Medical Centre+, Maastricht, Limburg, The Netherlands
| | - Geofridus van Merode
- Faculty of Health, Medicine and Life Sciences, Maastricht University Medical Centre+, Maastricht, Limburg, The Netherlands
| | - Jos Maessen
- Heart+Vascular Centre, Maastricht University Medical Centre+, Maastricht, Limburg, The Netherlands
| | - Reinier Zandbergen
- Heart+Vascular Centre, Maastricht University Medical Centre+, Maastricht, Limburg, The Netherlands.,Cardiothoracic Surgery, Amsterdam UMC Locatie AMC, Amsterdam, North Holland, The Netherlands
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Tellis R, Starobinets O, Prokle M, Raghavan UN, Hall C, Chugh T, Koker E, Chaduvula SC, Wald C, Flacke S. Identifying Areas for Operational Improvement and Growth in IR Workflow Using Workflow Modeling, Simulation, and Optimization Techniques. J Digit Imaging 2020; 34:75-84. [PMID: 33236295 DOI: 10.1007/s10278-020-00397-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 06/30/2020] [Accepted: 11/10/2020] [Indexed: 10/22/2022] Open
Abstract
Identifying areas for workflow improvement and growth is essential for an interventional radiology (IR) department to stay competitive. Deployment of traditional methods such as Lean and Six Sigma helped in reducing the waste in workflows at a strategic level. However, achieving efficient workflow needs both strategic and tactical approaches. Uncertainties about patient arrivals, staff availability, and variability in procedure durations pose hindrances to efficient workflow and lead to delayed patient care and staff overtime. We present an alternative approach to address both tactical and strategic needs using discrete event simulation (DES) and simulation based optimization methods. A comprehensive digital model of the patient workflow in a hospital-based IR department was modeled based on expert interviews with the incumbent personnel and analysis of 192 days' worth of electronic medical record (EMR) data. Patient arrival patterns and process times were derived from 4393 individual patient appointments. Exactly 196 unique procedures were modeled, each with its own process time distribution and rule-based procedure-room mapping. Dynamic staff schedules for interventional radiologists, technologists, and nurses were incorporated in the model. Stochastic model simulation runs revealed the resource "computed tomography (CT) suite" as the major workflow bottleneck during the morning hours. This insight compelled the radiology department leadership to re-assign time blocks on a diagnostic CT scanner to the IR group. Moreover, this approach helped identify opportunities for additional appointments at times of lower diagnostic scanner utilization. Demand for interventional service from Outpatients during late hours of the day required the facility to extend hours of operations. Simulation-based optimization methods were used to model a new staff schedule, stretching the existing pool of resources to support the additional 2.5 h of daily operation. In conclusion, this study illustrates that the combination of workflow modeling, stochastic simulations, and optimization techniques is a viable and effective approach for identifying workflow inefficiencies and discovering and validating improvement options through what-if scenario testing.
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Affiliation(s)
- Ranjith Tellis
- Philips Research North America, 222 Jacobs St, Cambridge, MA, 02141, USA.
| | - Olga Starobinets
- Philips Research North America, 222 Jacobs St, Cambridge, MA, 02141, USA
| | - Michael Prokle
- Philips Research North America, 222 Jacobs St, Cambridge, MA, 02141, USA
| | | | | | | | - Ekin Koker
- Philips Research North America, 222 Jacobs St, Cambridge, MA, 02141, USA
| | | | - Christoph Wald
- Medical Center Interventional Radiology, Lahey Hospital, 67 South Bedford Street, East Lobby, Burlington, MA, 01803, USA
| | - Sebastian Flacke
- Medical Center Interventional Radiology, Lahey Hospital, 67 South Bedford Street, East Lobby, Burlington, MA, 01803, USA
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Implementation of a Ponseti Clubfoot Program Decreases Major Surgery: A Quality Improvement Initiative. Pediatr Qual Saf 2020; 5:e362. [PMID: 33575522 PMCID: PMC7870159 DOI: 10.1097/pq9.0000000000000362] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 08/12/2020] [Indexed: 11/30/2022] Open
Abstract
Supplemental Digital Content is available in the text. Clubfoot describes a congenital condition. If untreated, clubfoot can cause long-term functional issues. The Ponseti method is the gold-standard treatment; it emphasizes casting over surgery. We identified a high rate of major recurrence in patients with isolated clubfoot at our institution. We implemented a quality improvement intervention to address the recurrences.
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Zepeda-Lugo C, Tlapa D, Baez-Lopez Y, Limon-Romero J, Ontiveros S, Perez-Sanchez A, Tortorella G. Assessing the Impact of Lean Healthcare on Inpatient Care: A Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17155609. [PMID: 32759705 PMCID: PMC7432925 DOI: 10.3390/ijerph17155609] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 07/23/2020] [Accepted: 07/29/2020] [Indexed: 12/16/2022]
Abstract
Healthcare services are facing challenges in increasing their efficiency, quality of care, and coping with surges in demand. To this end, some hospitals have implemented lean healthcare. The aim of this systematic review is to evaluate the effects of lean healthcare (LH) interventions on inpatient care and determine whether patient flow and efficiency outcomes improve. The review was performed according to PRISMA. We used six databases to search for studies published from 2002 to 2019. Out of 5732 studies, 39 measuring one or more defined outcomes were included. Hospital length of stay (LOS) was measured in 23 studies, 16 of which reported a reduction, turnover time (TOT) decreased in six out of eight studies, while the turnaround time (TAT) and on-time starts (OTS) improved in all five and seven studies, respectively. Moreover, eight out of nine studies reported an earlier discharge time, and the boarding time decreased in all four cases. Meanwhile, the readmission rate did not increase in all nine studies. Lastly, staff and patient satisfaction improved in all eight studies. Our findings show that by focusing on reducing non-value-added activities, LH contributed to improving patient flow and efficiency within inpatient care.
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Affiliation(s)
- Carlos Zepeda-Lugo
- Facultad de Ingeniería, Arquitectura y Diseño, Universidad Autónoma de Baja California, Ensenada 22860, Mexico; (C.Z.-L.); (J.L.-R.)
| | - Diego Tlapa
- Facultad de Ingeniería, Arquitectura y Diseño, Universidad Autónoma de Baja California, Ensenada 22860, Mexico; (C.Z.-L.); (J.L.-R.)
- Correspondence: (D.T.); (Y.B.-L.); Tel.: +52-6461750744 (D.T.)
| | - Yolanda Baez-Lopez
- Facultad de Ingeniería, Arquitectura y Diseño, Universidad Autónoma de Baja California, Ensenada 22860, Mexico; (C.Z.-L.); (J.L.-R.)
- Correspondence: (D.T.); (Y.B.-L.); Tel.: +52-6461750744 (D.T.)
| | - Jorge Limon-Romero
- Facultad de Ingeniería, Arquitectura y Diseño, Universidad Autónoma de Baja California, Ensenada 22860, Mexico; (C.Z.-L.); (J.L.-R.)
| | - Sinue Ontiveros
- Facultad de Ciencias de la Ingeniería, Administrativas y Sociales, Universidad Autónoma de Baja California, Tecate 21460, Mexico;
| | - Armando Perez-Sanchez
- Facultad de Ciencias de la Ingeniería y Tecnología, Universidad Autónoma de Baja California, Tijuana 22260, Mexico;
| | - Guilherme Tortorella
- Department of Systems and Production Engineering, Universidade Federal de Santa Catarina, Florianópolis 88040, Brazil;
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Ammanuel SG, Chan AK, DiGiorgio AM, Alazzeh M, Nwachuku K, Robinson LC, Lobo E, Mummaneni PV. Perioperative Anesthesia Lean Implementation Is Associated With Increased Operative Efficiency in Posterior Cervical Surgeries at a HighVolume Spine Center. Neurospine 2020; 17:390-397. [PMID: 32054140 PMCID: PMC7338954 DOI: 10.14245/ns.1938318.159] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 01/06/2020] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Lean management strategies aim to increase efficiency by eliminating waste or by improving processes to optimize value. The operating room (OR) is an arena where these strategies can be implemented. We assessed changes in OR efficiency after the application of lean methodology on perioperative anesthesia associated with posterior cervical spine surgeries. METHODS We utilized pre- and post-lean study design to identify inefficiencies during the perioperative anesthesia process and implemented strategies to improve the process. Patient characteristics were recorded to assess for differences between the 2 groups (group 1, prelean; group 2, post-lean). In the pre-lean period, key steps in the perioperative anesthesia process were identified that were amenable to lean implementation. The time required for each identified key step was recorded by an independent study coordinator. The times for each step were then compared between the groups utilizing univariate analyses. RESULTS After lean implementation, there was a significant decrease in overall perioperative anesthesia process time (88.4 ± 4.7 minutes vs. 76.2 ± 3.2 minutes, p = 0.04). This was driven by significant decreases in the steps: transport and setup (10.4 ± 0.8 minutes vs. 8.0 ± 0.7 minutes, p = 0.03) and positioning (20.8 ± 2.1 minutes vs. 15.7 ± 1.3 minutes, p = 0.046). Of note, the total time spent in the OR was lower for group 2 (270.1 ± 14.6 minutes vs. 252.8 ± 14.1 minutes) but the result was not statistically significant, even when adjusting for number of operated levels. CONCLUSION Lean methodology may be successfully applied to posterior cervical spine surgery whereby improvements in the perioperative anesthetic process are associated with significantly increased OR efficiency.
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Affiliation(s)
- Simon G Ammanuel
- Department of Neurosurgery, University of California San Francisco, San Francisco, CA, USA
| | - Andrew K Chan
- Department of Neurosurgery, University of California San Francisco, San Francisco, CA, USA
| | - Anthony M DiGiorgio
- Department of Neurosurgery, University of California San Francisco, San Francisco, CA, USA
| | - Mohanad Alazzeh
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Kelechi Nwachuku
- Department of Neurosurgery, University of California San Francisco, San Francisco, CA, USA
| | - Leslie C Robinson
- Department of Neurosurgery, University of California San Francisco, San Francisco, CA, USA
| | - Errol Lobo
- Department of Anesthesiology, University of California San Francisco, San Francisco, CA, USA
| | - Praveen V Mummaneni
- Department of Neurosurgery, University of California San Francisco, San Francisco, CA, USA
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Svenøy S, Watne LO, Hestnes I, Westberg M, Madsen JE, Frihagen F. Results after introduction of a hip fracture care pathway: comparison with usual care. Acta Orthop 2020; 91:139-145. [PMID: 31928088 PMCID: PMC7144204 DOI: 10.1080/17453674.2019.1710804] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - We established a care pathway for hip fracture patients, a "Hip Fracture Unit" (HFU), aiming to provide better in-hospital care and thus improve outcome. We compared the results after introduction of the HFU with a historical control group.Patients and methods - The HFU consisted of a series of measures within the orthopedic ward, such as reducing preoperative waiting time, increased use of nerve blocks, early mobilization, and osteoporosis treatment. 276 patients admitted from May 2014 to May 2015 constituted the HFU group and 167 patients admitted from September 2009 to January 2012 constituted the historical control group. Patients were followed prospectively up to 12 months post fracture.Results - Mean preoperative waiting time was 24 hours in the HFU group and 29 hours in the control group (p = 0.003). 123 patients (47%) in the HFU were started on anti-osteoporosis treatment while in hospital. "Short Physical Performance Battery" score (SPPB) was mean 5.5 in the HFU group and 3.8 in the control group at 4 months (p < 0.001), and 5.7 vs. 3.6 at 12 months (p < 0.001). The mortality rate at 4 months was 15% in both groups. No statistically significant differences were found in readmissions, complications, new nursing home admissions, in Barthel ADL index or a mental capacity test at the follow-ups.
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Affiliation(s)
- Stian Svenøy
- Division of Orthopaedic Surgery, Oslo University Hospital; ,Institute of Clinical Medicine, University of Oslo; ,Correspondence:
| | - Leiv Otto Watne
- Department of Geriatric Medicine, Oslo University Hospital, Norway
| | | | | | - Jan Erik Madsen
- Division of Orthopaedic Surgery, Oslo University Hospital; ,Institute of Clinical Medicine, University of Oslo;
| | - Frede Frihagen
- Division of Orthopaedic Surgery, Oslo University Hospital;
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Du G, Shi Y, Liu A, Liu T. Variance Risk Identification and Treatment of Clinical Pathway by Integrated Bayesian Network and Association Rules Mining. ENTROPY 2019. [PMCID: PMC7514536 DOI: 10.3390/e21121191] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
With the continuous development of data mining techniques in the medical field, variance analysis in clinical pathways based on data mining approaches have attracted increasing attention from scholars and decision makers. However, studies on variance analysis and treatment of specific kinds of disease are still relatively scarce. In order to reduce the hazard of postpartum hemorrhage after cesarean section, we conducted a detailed analysis on the relevant risk factors and treatment mechanisms, adopting the integrated Bayesian network and association rule mining approaches. By proposing a Bayesian network model based on regression analysis, we calculated the probability of risk factors determining the key factors that result in postpartum hemorrhage after cesarean section. In addition, we mined a few association rules regarding the treatment of postpartum hemorrhage on the basis of different clinical features. We divided the risk factors into primary and secondary risk factors by realizing the classification of different causes of postpartum hemorrhage after cesarean section and sorted the posterior probability to obtain the key factors in the primary and secondary risk factors: uterine atony and prolonged labor. The rules of clinical features associated with the management of postpartum hemorrhage during cesarean section were obtained. Finally, related strategies were proposed for improving medical service quality and enhancing the rescue efficiency of clinical pathways in China.
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Affiliation(s)
- Gang Du
- School of Business and Administration, Faculty of Economics and Management, East China Normal University, Shanghai 200062, China; (G.D.); (Y.S.)
| | - Yinan Shi
- School of Business and Administration, Faculty of Economics and Management, East China Normal University, Shanghai 200062, China; (G.D.); (Y.S.)
| | - Aijun Liu
- Department of Management Engineering, School of Economics & Management, Xidian University, Xi’an 710071, China;
- Correspondence: ; Tel.: +86-181-9213-6778
| | - Taoning Liu
- Department of Management Engineering, School of Economics & Management, Xidian University, Xi’an 710071, China;
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Haugan K, Johnsen LG, Basso T, Foss OA. Mortality and readmission following hip fracture surgery: a retrospective study comparing conventional and fast-track care. BMJ Open 2017; 7:e015574. [PMID: 28851773 PMCID: PMC5724094 DOI: 10.1136/bmjopen-2016-015574] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 06/08/2017] [Accepted: 07/26/2017] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE To compare the efficacies of two pathways-conventional and fast-track care-in patients with hip fracture. DESIGN Retrospective single-centre study. SETTING University hospital in middle Norway. PARTICIPANTS 1820 patients aged ≥65 years with hip fracture (intracapsular, intertrochanteric or subtrochanteric). INTERVENTIONS 788 patients were treated according to conventional care from April 2008 to September 2011, and 1032 patients were treated according to fast-track care from October 2011 to December 2013. PRIMARY AND SECONDARY OUTCOME Primary: mortality and readmission to hospital, within 365 days follow-up. Secondary: length of stay. RESULTS We found no statistically significant differences in mortality and readmission rate between patients in the fast-track and conventional care models within 365 days after the initial hospital admission. The conventional care group had a higher, no statistical significant mortality HR of 1.10 (95% CI 0.91 to 1.31, p=0.326) without and 1.16 (95% CI 0.96 to 1.40, p=0.118) with covariate adjustment. Regarding the readmission, the conventional care group sub-HR was 1.02 (95% CI 0.88 to 1.18, p=0.822) without and 0.97 (95% CI 0.83 to 1.12, p=0.644) with adjusting for covariates. Length of stay and time to surgery was statistically significant shorter for patients who received fast-track care, a mean difference of 3.4 days and 6 hours, respectively. There was no statistically significant difference in sex, type of fracture, age or Charlson Comorbidity Index score at baseline between patients in the two pathways. CONCLUSIONS There was insufficient evidence to show an impact of fast-track care on mortality and readmission. Length of stay and time to surgery were decreased. TRIAL REGISTRATION NUMBER NCT00667914; results.
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Affiliation(s)
- Kristin Haugan
- Department of Orthopaedics, Orthopaedic Research Centre, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Lars G Johnsen
- Department of Orthopaedics, Orthopaedic Research Centre, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, NTNU, Trondheim, Norway
| | - Trude Basso
- Department of Orthopaedics, Orthopaedic Research Centre, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Olav A Foss
- Department of Orthopaedics, Orthopaedic Research Centre, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
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Govaert GAM, Glaudemans AWJM, Ploegmakers JJW, Viddeleer AR, Wendt KW, Reininga IHF. Diagnostic strategies for posttraumatic osteomyelitis: a survey amongst Dutch medical specialists demonstrates the need for a consensus protocol. Eur J Trauma Emerg Surg 2017; 44:417-426. [PMID: 28331952 PMCID: PMC6002444 DOI: 10.1007/s00068-017-0783-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 03/10/2017] [Indexed: 12/17/2022]
Abstract
Introduction Posttraumatic osteomyelitis (PTO) is a feared complication after surgical fracture care. Late diagnosis can result in interrupted and prolonged rehabilitation programmes, inability to work, medical dependency, unnecessary hospital admissions, and high medical and non-medical costs. Primary aim of this study was to assess preferred diagnostic imaging strategies for diagnosing PTO amongst orthopaedic and trauma surgeons, radiologists, and nuclear medicine physicians. Secondary aims were to determine the preferred serum inflammatory marker for diagnosing PTO and the existence of a local hospital protocol to diagnose and manage PTO. Materials and methods This study utilised an online survey based on four clinical scenarios, varying from early to late onset of PTO. It was designed to assess individual practitioners’ current preferred diagnostic strategy for diagnosing PTO. Eligible study participants were medical specialists and registrars in orthopaedic and trauma surgery, musculoskeletal (MSK) radiology, and nuclear medicine. Results There were 346 responders: 155 trauma surgeons, 102 orthopaedic surgeons, 57 nuclear medicine physicians, and 33 MSK radiologists. Trauma surgeons favour FDG-PET to image PTO, while orthopaedic surgeons prefer WBC scintigraphy. A similar difference was seen between radiologists and nuclear medicine physicians (MRI versus nuclear medicine imaging). CRP was regarded as the most useful serum inflammatory marker. Only one-third of all responders was aware of a local hospital protocol for the treatment of osteomyelitis. Conclusions The availability of and awareness towards local protocols to diagnose and treat PTO is poor. The results of this study support the need for future randomised controlled trials on optimal diagnostic strategies for PTO.
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Affiliation(s)
- G A M Govaert
- Department of Surgery, Subdivision of Trauma Surgery, University of Groningen, University Medical Center Groningen, P.O. Box 30001, 9700 RB, Groningen, The Netherlands. .,Department of Trauma Surgery, University Medical Center Utrecht, Internal mail no G04.228, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands.
| | - A W J M Glaudemans
- Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, P.O. Box 30001, 9700 RB, Groningen, The Netherlands
| | - J J W Ploegmakers
- Department of Orthopaedics, University of Groningen, University Medical Center Groningen, P.O. Box 30001, 9700 RB, Groningen, The Netherlands
| | - A R Viddeleer
- Department of Radiology, University of Groningen, University Medical Center Groningen, P.O. Box 30001, 9700 RB, Groningen, The Netherlands
| | - K W Wendt
- Department of Surgery, Subdivision of Trauma Surgery, University of Groningen, University Medical Center Groningen, P.O. Box 30001, 9700 RB, Groningen, The Netherlands
| | - I H F Reininga
- Department of Surgery, Subdivision of Trauma Surgery, University of Groningen, University Medical Center Groningen, P.O. Box 30001, 9700 RB, Groningen, The Netherlands
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Pinney SJ, Page AE, Jevsevar DS, Bozic KJ. Current concept review: quality and process improvement in orthopedics. Orthop Res Rev 2015; 8:1-11. [PMID: 30774466 PMCID: PMC6209351 DOI: 10.2147/orr.s92216] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Multiple health care stakeholders are increasingly scrutinizing musculoskeletal care to optimize quality and cost efficiency. This has led to greater emphasis on quality and process improvement. There is a robust set of business strategies that are increasingly being applied to health care delivery. These quality and process improvement tools (QPITs) have specific applications to segments of, or the entire episode of, patient care. In the rapidly changing health care world, it will behoove all orthopedic surgeons to have an understanding of the manner in which care delivery processes can be evaluated and improved. Many of the commonly used QPITs, including checklist initiatives, standardized clinical care pathways, lean methodology, six sigma strategies, and total quality management, embrace basic principles of quality improvement. These principles include focusing on outcomes, optimizing communication among health care team members, increasing process standardization, and decreasing process variation. This review summarizes the common QPITs, including how and when they might be employed to improve care delivery.
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Affiliation(s)
- Stephen J Pinney
- Department of Orthopaedic Surgery, St Mary's Medical Center, San Francisco, CA, USA,
| | - Alexandra E Page
- Orthopaedic Surgery, AAOS Health Care Systems Committee, San Diego, CA, USA
| | - David S Jevsevar
- Department of Orthopaedics, Geisel School of Medicine, Dartmouth University, Hanover, NH, USA
| | - Kevin J Bozic
- Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas, Austin, TX, USA
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Gjerde AM, Aa E, Sund JK, Stenumgard P, Johnsen LG. Medication reconciliation of patients with hip fracture by clinical pharmacists. Eur J Hosp Pharm 2015; 23:166-170. [PMID: 31156840 DOI: 10.1136/ejhpharm-2015-000741] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 10/07/2015] [Accepted: 10/12/2015] [Indexed: 11/04/2022] Open
Abstract
Objective Medication reconciliation is a strategy for reducing medication discrepancies and improving patient safety. Transitions through different levels of care contribute to medication discrepancies caused by lack of communication. In October 2011, St Olav's Hospital initiated a fast-track model for patients with hip fractures, where clinical pharmacists (CPs) are a part of a multidisciplinary team. The purpose of this study was to examine discrepancies discovered in medication lists by CPs at the orthopaedic ward and consider their clinical relevance. Method This prospective study was conducted at an orthopaedic ward at St Olav's Hospital in the period October 2011-August 2012. Medication reconciliation by CPs was done for all patients with a hip fracture using a systematic method. Information was obtained by the CP by interview with the patient and additional sources, for example, medication list from general practitioner and nursing home. An independent expert group consisting of a geriatrician, an orthopaedist and a CP considered level of clinical relevance of the discrepancies found in the collected data. Results A total of 410 discrepancies were registered for all 317 patients, Discrepancies were found in 159 (50%) patients with an average of 2.6 per patient affected. Of the total amount of discrepancies, the expert group evaluated 68% and 19% as potentially moderate and severe, respectively, if they were unattended during hospitalisation and after discharge. Conclusions By using CPs in medication reconciliation at orthopaedic wards, discrepancies that can lead to serious discomfort or clinical deterioration of patients can be avoided.
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Affiliation(s)
| | | | - Janne Kutschera Sund
- Central Norway Hospital Pharmacy Trust, Trondheim, Norway.,Department of Laboratory Medicine, Children's and Women's Health, Norwegian University of Science and Technology, Trondheim, Norway
| | - Pal Stenumgard
- Department of Geriatrics, St Olav's Hospital, University Hospital of Trondheim, Trondheim, Norway
| | - Lars Gunnar Johnsen
- Department of Orthopaedic Surgery, St Olav's Hospital, University Hospital of Trondheim, Trondheim, Norway.,Department of Neuroscience, Norwegian University of Science and Technology, Trondheim, Norway
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Bertolaccini L, Viti A, Terzi A. The Statistical point of view of Quality: the Lean Six Sigma methodology. J Thorac Dis 2015; 7:E66-8. [PMID: 25973253 DOI: 10.3978/j.issn.2072-1439.2015.04.11] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Accepted: 02/28/2015] [Indexed: 11/14/2022]
Abstract
Six Sigma and Lean are two quality improvement methodologies. The Lean Six Sigma methodology is applicable to repetitive procedures. Therefore, the use of this methodology in the health-care arena has focused mainly on areas of business operations, throughput, and case management and has focused on efficiency outcomes. After the revision of methodology, the paper presents a brief clinical example of the use of Lean Six Sigma as a quality improvement method in the reduction of the complications during and after lobectomies. Using Lean Six Sigma methodology, the multidisciplinary teams could identify multiple modifiable points across the surgical process. These process improvements could be applied to different surgical specialties and could result in a measurement, from statistical point of view, of the surgical quality.
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Affiliation(s)
- Luca Bertolaccini
- 1 Thoracic Surgery Unit, Sacro Cuore-Don Calabria Research Hospital, Negrar Verona, Italy ; 2 Thoracic Surgery Unit, S. Croce e Carle Hospital, Cuneo, Italy
| | - Andrea Viti
- 1 Thoracic Surgery Unit, Sacro Cuore-Don Calabria Research Hospital, Negrar Verona, Italy ; 2 Thoracic Surgery Unit, S. Croce e Carle Hospital, Cuneo, Italy
| | - Alberto Terzi
- 1 Thoracic Surgery Unit, Sacro Cuore-Don Calabria Research Hospital, Negrar Verona, Italy ; 2 Thoracic Surgery Unit, S. Croce e Carle Hospital, Cuneo, Italy
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